The professional caregiver is able to autonomously and independently perform the documentation process. | The professional caregiver is able to: - document collected data properly (e.g. handwritten, electronic documentation systems),
- differentiate between data relevant and irrelevant for documentation,
- extract required data from the documentation to perform tasks,
- share data with internal and external partners (e.g. send faxes, e-mails, use apps),
- make updates to the facility’s patient management system (e.g. for patient’s/client’s registration),
- place orders according to the system of the facility (e.g. food orders, material orders, pharmacy orders),
- trigger repair requests (e.g. for medical equipment),
- perform wound documentation according to the in-house system (e.g. special description of wounds, photo documentation) (see also CA.3.3),
- write letters using office programs (e.g. care report when transferring patients/clients),
- make diverse kinds of printouts (e.g. print monitor image, print out letters, use printer on defibrillators),
- cooperate with in-house stakeholders who require data from the documentation (e.g. phoning with attending physician to transfer data),
- ensure completeness and accuracy in service handovers at shift changes,
- document visits and write detailed reports.
| The professional caregiver is able to: - describe the legal basis and ownership of documented data,
- describe the objectives of the documentation and the documentation system,
- explain what information can be gathered from the documentation system to serve patients/clients,
- designate legal basis and regulations for the exchange of data (e.g. name the owner of the data),
- explain the functions of the patient management system,
- name data associated with patients/clients (e.g. case number, family doctor, contact with relatives),
- explain the procedure for order processes,
- describe the procedure for repair requirements,
- name reasons for continuous wound documentation (e.g. legal basis, observing changes),
- describe the execution of a wound documentation (see also CA.3.3),
- name office programs (e.g. word processing, spreadsheet program)
- name functions of office programs,
- name data that must be included in the report of care when transferring patients/clients and justify it,
- describe the procedure for printing letters,
- name important telephone numbers inside and outside the facility (e.g. attending physician, house emergency number),
- explain the proper identification of patients/clients.
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